Vietnam: Height Initiative Faces Growing Criticism

The Vietnamese government recently announced an ambitious USD 287 million plan aimed at increasing the average height of Vietnamese men and women. The plan seeks to raise height averages for 18-year-old men and women from current meager figures of 1.67 and 1.56 meters to 1.685 meters and 1.575 meters, respectively, by 2030. These statistics place Vietnamese people among the shortest in the region. Approved by Prime Minister Nguyen Tan Dung in 2011, the plan targets pregnant women and children from birth until 18 years of age. Action programs work to increase awareness and promote healthy habits, with heavy—almost exclusive—emphasis on milk consumption.1

Source: Khanh Hmoong

At the core of this multimillion-dollar endeavor is the premise that the short stature of the Vietnamese people is caused by poor nutrition and lack of physical activity. In motivating the project, co-mastermind Dr. Do Thi Kim Lien of the National Nutrition Institute estimates the influence of genes on adult height to be only 23%, compared to 31% for nutrition, 20% for physical exercise, and 16% for environmental and other factors. Dr. Lien stresses the critical importance of school feeding programs, in particular the success of the Sữa học đường (literally translated as Milk in Schools) initiative, which collaborates with Vinamilk, Vietnam’s largest dairy corporation, to provide a glass of milk for preschool and elementary school children three times a week for the entire nine months of the school year.2

The feasibility of the plan has been put into serious question, and for a good number of reasons.

A FRAGMENTED VIEW OF NUTRITION

In November of last year, VTV (Vietnam Television) partnered with the Ministry of Education to carry out a program called Vươn cao tầm vóc Việt (literally translated as Reaching for a New Vietnamese Height), which provided free physical checkups and nutritional advice for optimum growth achievement to students in Hanoi’s public junior high schools. The official broadcast of the program shows masses of students having their height- and weight-for-age taken, as well as bone mass measurements. Even more, the broadcast shows adult height figures being predicted, before cutting to a brief interview with a student who states, rather robotically, that she will strive “to drink more milk, exercise more, and sleep before 11pm.”3 The more than two thousand students who participated in the program went home with the same message.

Current recommendations single out one “special” food—milk—and one “special” nutrient—calcium—for height growth and bone health. This and other similar initiatives fail to question whether milk’s predominance among available sources of calcium is ideal. A critical effect of this black-and-white, single-nutrient, single-food view is a woeful lack of knowledge of equally, if not more, efficient nutrient sources. Indeed, milk is promoted in Vietnam as a height-boosting super-food, to the exclusion of other calcium-packed non-dairy options.

While milk is certainly calorie-dense and nutrient-rich, we cannot cherry-pick nutrients in our food to absorb, but must instead consume the whole package. Overconsumption of calcium solely from milk, as it turns out, may even put one at risk to detrimental side effects from its other components.

Historically, numerous national height initiatives in Vietnam resulted in milk-drinking crazes, with the country ultimately ranking among the highest in milk consumption growth. Sales of white, flavored, and powdered milk along with other drinking milk products pushed VND 23.1 trillion (USD 1.1 billion) in 2013, a near-quadruple increase from eight trillion Vietnamese Dong (USD 379 million) in 2008.4 My childhood memories, for one, are riddled with colorful cartons of strawberry- and orange-flavored milk and drinking yogurt, which have become wildly popular in Vietnam in recent decades as break-time or after-school snacks.

In her book Re-imagining milk, Audrey Wiley points out the fact that politically and economically powerful nations tend to have the highest levels of milk consumption and the tallest citizens. This idea “creates a package of meanings that allows milk consumption to be an essential ‘mark of new money.’” While this may explain the privileged status of milk in national nutritional recommendations and school feeding programs,5 there is little scientific evidence to support this favoritism.

Source: Guy Montag

First, it is likely that the recommended intake of calcium is highly exaggerated. The minimum requirement based on scientific research is a mere 150-200 mg a day for adults. Citizens of many underdeveloped countries—much of the world’s population—consume 300-500 mg/day and develop healthy adult skeletons.6 Based on this observation, the World Health Organization acknowledges that 500 mg is sufficient, though they ultimately recommend an inflated 1000 mg.7 Meanwhile, the USA Food and Nutrition Board recommends up to 1000-1300 mg/day, and the National Nutrition Institute of Vietnam has followed in its footsteps. Thus, according to this standard, the 482 mg average daily calcium intake of Vietnamese people puts most people in the category of calcium deficiency, when they still consume well above the minimum requirement.8

Secondly, according to Nguyen Van Tuan, senior researcher on bone genetics at the Garvan Institute of Medical Research in Australia, there is very little evidence that genes only account for 23% of adult height achievement. The actual figure, Tuan notes, is likely to be much higher at 65-87%.9 Most importantly, deeply entrenched as it is, the view that height growth necessarily requires milk consumption remains unsubstantiated. Indeed, despite strong historical correlations between dairy consumption and height increase, studies that even begin to establish a causal relation between milk consumption and growth are virtually nonexistent. The few controlled supplementation trials that have been performed lack even a control group with any caloric equivalent of the milk supplement, making it impossible to draw conclusions about how milk consumption leads to differences in growth. These differences rarely exceed 1 cm in the first place, and the studies do not distinguish between the effects of the specific supplement and those of the higher general caloric intake.10

Further studies discount the widely accepted claim that drinking milk builds strong bones. The Harvard Nurses’ Health Study, a 12-year study of 78,000 women, found that women who drank milk three times a day later suffered from more fractures than those who rarely drank milk.11 A 1994 study of elderly men and women in Sydney, Australia similarly showed that higher dairy consumption was actually associated with increased fracture risk.12 Although a premature conclusion, the studies at the very least underscore that milk consumption growth can not be used as an appropriate metric for measuring health improvement.

Compelling evidence suggests that deriving calcium from milk may result in increased rates of obesity and chronic diseases. According to Moschos & Mantzoros (2002), published in Oncology, the rise in Insulin-like growth factor I (IGF-1) levels is a powerful promoter of growth for cancers of the breast, prostate, lung, and colon.13 These findings are corroborated by provocative results from a large-scale study that documents in-depth interviews with tens of thousands of Japanese each year, analyzing diets and rates of major “diseases of modernity” since 1946. The study shows that in the same time frame that dairy consumption in Japan increased 15-fold from 5.5 pounds of dairy products per capita per year to 117.4 pounds, rates of cerebral vascular disease (strokes) increased by 38%, heart disease by 35%, and breast cancer and colon cancer by 77%. Furthermore, the physiology of young Japanese girls was also greatly altered, with the average girl experiencing menarche more than 3 years earlier.14

Despite its important implications, the study largely fell into oblivion. The view that a diet without animal protein, like dairy, is not inherently “deficient” remains unpopular today, preventing critical scientific findings from reaching the radar of policy-makers.

A SUPERFICIAL GOAL

At some point, one must ask if the goal of the Vietnamese government’s height initiative is a superficial, height-based national power or health improvement. These height initiatives raise a real public health threat—they divert attention away from the country’s actual health challenges. Van Tuan notes pointedly that the money funneled into height programs would be more wisely invested in improving overall standards of living, including, for example, those of rural children stunted by malnutrition.15

Indeed, due to major budgetary constraints, as much as half of the population still lacks basic necessities such as clean water, which contributes to the continued prevalence of preventable infectious diseases—notably, malaria. Despite impressive progress since the 1990s, Vietnam’s healthcare system continues to face quality and access issues that often plague developing nations. In the 1990-2009 period, the infant mortality rate fell from 44.4% to 16.0%, the under-five mortality rate from 58.0% to 24.5%, and the maternal mortality ratio from 233 to 69 deaths per 100,000 live births.16 However, these levels remain concerning and are rooted in systemic issues that could be alleviated with greater governmental attention.

Specifically, weak incentives for doctors and healthcare providers to serve rural locals contributes to not only a general shortage of qualified health professionals but also a concentration of resources in urban areas. There is an overwhelming focus on the wealthier sections of society,17,18 while lower-income Vietnamese face a myriad of access barriers. Assuming access is possible, people must navigate through “maddeningly opaque bureaucracies,” countless “informal fees,” and their own distrust in the healthcare system.19

According to Nguyen Duc Hinh, president of Hanoi Medical University, equity-centered concerns must be a major focus for the success of the health system in Vietnam.20 With this in view, attention to height initiatives retards progress by erroneously shifting focus from the need for comprehensive reforms in at-risk communities to small-scale changes that have little meaning outside of the context of a middle-class, urban population. At a time when the majority of resources should be going towards furnishing basic healthcare services and rebuilding trust in a healthcare network, height efforts strike many as wasteful and absurd.

Ultimately, failure to consider all relevant scientific literature, together with a one-sided understanding of nutrition, give reason to doubt the feasibility and effectiveness of current measures to raise the height of Vietnamese people. Focusing on this superficial indicator detracts from more urgent equity-based public health concerns. These observations reveal a critical need to reconsider domestic height initiatives as a whole.

Hanh Nguyen is a junior in Morse College majoring in Sociology. She can be contacted at hanh.nguyen@yale.edu.